Morbidity and Mortality Whats making us sick

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Integrated Health Networks Learning Session
2 February 5th, 2008
Presented by Dr. Stephen Brown, Assistant
Deputy Minister, Medical Services Division,
Health System Planning Division, Ministry of
Health
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• On A Journey

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Patient and the health care labyrinth
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Health professional the health care system
labyrinth
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Avoiding the Dangers of An Unresolved Excursion
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(1) Make Sure You Have a Good Map

• Health System PlanningHelping You Navigate Your
  Way

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Need/End
Clearly Articulated Deliverables
HA/Physician Delivery Vehicles
MoH Delivery Enablers/Constraints
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Health System Making a Plan
Need
gap
Value Propositions/Outcomes For
Population/Patient
Value Propositions/Outcomes For
Fiduciary/Financial
reconcile
gap
HA Community Delivery Vehicles (HCC/Residential,
MHA, Clinics Hospital
gap
Program parameters/policy
GP FSP
Community Partners
gap
System Organization Parameters Resources/Learning
Growth
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Need
gap
Value Propositions/Outcomes For
Population/Patient
Value Propositions/Outcomes For
Fiduciary/Financial
reconcile
gap
HA Community Delivery Vehicles (HCC/Residential,
MHA, Clinics Hospital
gap
Program parameters/policy
GP FSP
Community Partners
gap
System Organization Parameters Resources/Learning
Growth
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(2) Passion Commitment Definitely, But Also A
Big Enough Engine
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Passionate about the value of quality primary
care for patients
A commitment and drive to be the best in
providing high quality primary care to patients

• The right engine
• Integration
• Transformation
• Continuous Improvement

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(1) Real Meaningful Integration

• Identifying redundancies and gaps to bring
  services together for the patient and delivering
  high quality care - the value proposition for the
  patient
• Supporting quality professional practice, quality
  working environment, valuing each other, and
  work-life balance - the value proposition for our
  physicians, nurse practitioners, nurses, MOAs,
  allied health and community partners.

Primary Care Home
Patient

• Hospital
• ER
• Specialists
• Mental Health
• HCC

Community Resources
Access
Continuous
Comprehensive
Coordinated
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(2) Transformational vs Incremental Change
Transformed system
Carve-out model

• Project mentality
• CDM modelled locally
• Outcomes improvements locally, silos of
  excellence
• Care gaps remain
• Variation increased
• Fragmentation

• Planned proactive care
• Fully integrated care
• Guidelines embedded in care
• Patients as partners, community engagement
• Outcomes improved at the macro level
• Variation minimized

Level of Technical Change
Modified system
Status quo

• Philosophic shift with rhetoric
• Project mentality
• Some local readiness for change
• Care gaps remain
• Variation increased

• Acute, episodic care
• Care gaps
• Fragmentation of care
• Variable outcomes
• Patient as client
• Silos for primary, secondary care

Level of Adaptive Change
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What do we mean by a transformation primary
care system - planned incremental organizational
change is messy, transformational organizational
change is very messy

• Organizations have archetype coherence in which
  their structures and processes of organization
  design consistently reflect and reinforce one
  interpretive scheme (beliefs and values about
  domain/focus of practice, principles of
  organizing, and criteria for evaluating
  performance)
• Transformational change implies a shift from one
  interpretive scheme and how it relates to
  structural attributes and processes to another
  interpretive scheme and new structural attributes
  and processes
• The possibilities and limitation of change in any
  organization are influenced by the history of
  attitudes and relationships between interest
  groups and by the mobilization of support for a
  change within the power structure at any point in
  time

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Where are we in the change process right now?
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(No Transcript)
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What are our chances for transformational change
according to Hinings and Greenwood

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What do I have to do to make a difference?

• Collaborative leadership to get things done
  within a diffuse power structure
• Build pockets of change that together can lead to
  a tipping point to schizoid incoherence and
  beyond!

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(3) Continuous Improvement (1) ECCM
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Continuous Improvement(2) PDSA Model for
Improvement
The primary goal of improvement science is to
increase the likelihood that a change will
actually result in sustained improvement. NHA
Improvement Guide
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Continuous Improvement(3) Learning Model
The Breakthrough Series, 2003, IHI.org
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So Where Exactly Are We On This Journey?
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A reminder on our agreed focus more complex
populations
Patient Health Status
Co-morbid
Palliative
Healthy
Chronic
At risk
Frail
Family
Community
GP
Supports
Specialist
Public Health
Home CC
Mental Health
Hospital/ER
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A range of Primary Health Care Initiatives
Improved Health and Wellness for British
Columbians'
High Quality Patient Care
A sustainable, affordable, publicly funded health
system
Health Goals
Stay Healthy
Varying Health Status
Get Better
Manage Disease and Disability
Coping with end of life
Important PHC Features
Accessible
Continuous
Comprehensive
Coordinated
Build healthy public policy
Create supportive environments
Health System / Organization
ECCM
Strengthen community action
Self management / Develop personal skills
Delivery system design / Reorient health services
Decision support
Information systems
Practice support teams
Family Practice Divisions?
PHC Charter
GP Services Committee
eHealth
Patient registers
QI school
PHC home for British Columbians
Patients as partners
CDM Toolkit
CHF
Integrated Health Networks
Closing gaps in care through CDM initiatives
A
Improved general access to primary health care
Diabetes
Supports
Community and facility patient conferencing
Hypertension
B
Increased access to primary care providers for
maternity care
Planned complex care
C
Increased chronic disease prevention
GPAC Guidelines and Protocols
Prevention - Cardiovascular risk assessment
D
GPSC Initiative Evaluation
Cardiovascular cluster
Musculoskelatal cluster
Enhanced management of chronic diseases
Maternity network / GP obstetrics
Stroke (Heart Stroke)
Arthritis (Arthritis Society)
E
Depression
Respiratory cluster
Mental health initiatives
Guided self-management (CMHA)
F
Improved coordination and approaches to manage
co-morbidities
Service frameworks
Dementia (Alzheimer society)
Population based analysis action
Retain and recruit family physicians
G
Improved care for the frail elderly
Strengthen GP/Specialist links
Practice support program
H
Frail elderly collaborative
Enhanced end of life care
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More specifically - summary of initiatives by HA
Actual numbers may be lower based on overlap.
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IHN Three Year Funding Commitment
MSD/HA sustainability funding to support the PHC
Charter
08/09 Funding
09/10 Funding
07/08 Funding
22.8 Million from HIF
24 Million (12M MSD / 12M from HAs)
24 Million (12M MSD / 12M from HAs)
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IHNs As A Key Vehicle for Change

• The BC government recognizes that through IHNs,
  we can improve the health of British Columbians
  by providing planned, coordinated care for the
  whole patient, rather than separate services
  reacting to isolated health issues.
• An IHN team is a formal partnership between a
  patient, their family doctor, and select
  healthcare practitioners.
• The patients family doctor coordinates the team
  in producing and acting on a health care plan
  customized for the individual patient.
• Accountability for results lies collectively with
  all members of the IHN. Results will be clearly
  measured, assessed and communicated to all
  partners.

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Expected results

• Increased patient confidence and sense of control
  in managing his/her own health no more
  full-time patients.
• Improved quality of care. Improved quality of
  life.
• Economic gain Improved health outcomes relative
  to a patients overall medical condition per
  dollar invested.
• Improved health satisfaction more results,
  better feedback, less duplication, fewer
  communication gaps, best use of everyones time.
• Effective integration of primary care, local and
  regional resources increased mutual
  understanding of methods and priorities of care.
• Better supported providers who have more
  confidence in the system and its ability to
  support them and their patients.
• A healthier population.

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How will Integrated Health Networks be evaluated?
ECCM Process Measures (2 per domain varies by
IHN) Lead Indicators
Outcome Measures (Consistent across the
province) Lag Indicators
Improving patient access to PHC
Build healthy public policy
Create supportive environment
Improving patient health outcomes through quality
improvement
Strengthen community action
Self management / Develop personal skills
Improving patient confidence and experience with
the health system
Delivery system design / Reorient health services
Decision support
Improving provider confidence and experience with
the health system
Information systems
Decreasing the average annual cost per patient
Health System / Organization
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IHNs are closely related to the PSP
BCMA, MOH and HAs have a collective
responsibility for success
Integrated change management support for BC
physicians
Clinical
1900 physicians
Quality learning network under development -
ImpactBC
IM/IT
Practice Management
200 people trained

• Focus on
• optimal patient care and access to care
• clinical value for physicians
• practice efficiencies
• supportive IMIT tools
• coordinated local support resources

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What weve achieved to date

• Common purpose.
• We continue to build a shared understanding and
  experience with IHNs.
• Bi-lateral agreements have introduced
  discipline.
• We are building relationships where they
  previously didnt exist.
• Increasing awareness of the need for a shift to a
  culture of continuing improvement.
• We are relentlessly persevering.

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Integrated Health Networks Roadmap
08/09
09/10
07/08
PSP Team Training Session III IV
IHN report I II
ECCM indicators
Provincial Sessions
IHN Congress
LS3
LS5
LS6
LS1
LS2
AP
AP
AP
AP
Nov 27/28 2008
Nov 2009
Mar 2010
Sep 13/14 2007
Feb 7/8 2008
LS4
LS4
LS4
Apr 2009
Regional learning sessions?
LS4
LS4
Regional Sessions
LS
LS
LS
LS
LS
LS
AP
AP
AP
AP
AP
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• Leadership excellence in high performing
  organizations does not begin with vision, goals
  or plans. It begins with getting people to
  confront the brutal facts and to act in a
  disciplined way on the implications
• the leadership hold the organization accountable
  for achievement in the outputs not the quantity
  of inputs
• the leadership gets things done with a diffuse
  power structure breaking through the system
  inertia to create unstoppable momentum
• J Collins, Good to Great